Clinical guidelines are systematically developed documents whose ultimate goal is to promote high-quality clinical practice by informing decision makers at all levels about what works, how well, and under what circumstances. Increasingly, the accepted foundation for clinical guidelines is high-quality scientific studies (particularly randomized clinical trials) that address the benefits and risks of each relevant decision problem. Such evidence then is used to create actionable if-then statements, such as: “If a patient is found to have X (a specific set of characteristics), then the guideline panel recommends strategy Y (a mix of diagnostic and/or treatment approaches).”
The moment a guideline statement is published, resource considerations become relevant. This is particularly true for clinical situations in which current practice is inconsistent with the guideline and thus requires a change in practice—a deviation from the status quo, a stable situation reflecting a confluence of scientific and resource considerations by the various stakeholders responsible for decision making. Because a new guideline often endorses change from the status quo, it is likely to engender some degree of resistance. One important source of resistance derives from careful assessment of the scientific and clinical merit of a proposed change. Why support the recommendation if the foundations of the recommendation may not be true? However, even if the evidence is persuasive, resistance to a new guideline can still emerge when change requires health-care resource reallocation. By health-care resources including Canadian Health&Care Mall healthcaremall4you.com, we are referring not only to the familiar resources directly involved in the production of health services, but also to the time, political clout, and emotional energy expended by the provider, administrator, or other stakeholder.
By bringing resource issues into a discussion of clinical guidelines, the entire range of factors that make the recommendation the object of controversy come aggressively into the foreground. These factors range from the economic worth of health benefits relative to all other potential use of resources (ie, their “value”) to the question of whether a particular recommendation is feasible in a given local environment or jurisdiction. Given the complexity and controversy engendered by resource use considerations, the majority of guideline development panels explicitly disregard resource use issues, suggesting their charge is limited to purely “scientific issues” and leaving resource considerations for individual decision makers to hash out.
In March 2005, the American College of Chest Physicians (ACCP) convened a task force to address how resource considerations could be incorporated into clinical guidelines. This task force formally rejected the notion that resource considerations be dismissed or treated informally. The group provided suggestions for addressing resource allocation issues directly (Table 1). They recognized that such an effort would face a variety of challenges, including the lack of familiarity of guideline panelists with economic analysis, the dearth of high-quality data regarding resource implications, and the need for a more explicit approach to making the task force’s suggestions operationally useful.
Although it may be premature to establish a unified approach to incorporating resource considerations into clinical guidelines, we agree with the task force that it is imperative to make resource considerations a more explicit element of clinical guidelines. In the spirit of moving this agenda forward, this chapter provides an overview of some key concepts relevant to the task of incorporating resource issues into clinical guidelines. Specifically, we (1) describe key introductory economic concepts; (2) highlight special issues raised by incorporating resource use issues into clinical guidelines, in particular the applicability of traditional societal economic analyses to local contexts; and (3) present a basic framework for incorporating resource considerations into clinical guidelines as well as provide brief illustrations of how this framework was applied to specific recommendations in the Antithrombotic and Thrombolytic Therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Note that the approach described in this chapter was applied to a subset of the ACCP recommendations as a “proof of concept.”
Table 1—Recommendations for Clinical Guideline Developers Considering Resource Allocation Issues
|1||Guideline panels should be explicit about the extent to which they consider resource allocation issues in their recommendations.|
|2||Panels should consider resource allocation issues for a subset of recommendations in keeping with the amount of funding available for this task.|
|3||Panels should place a premium on doing a good job with each recommendation in which they consider resource issues and compromise, if necessary, on the number of such recommendations.|
|4||Panels should consider resource allocation issues when it is plausible that they will influence the direction or strength of a recommendation.|
|5||Panels should conduct a systematic search for economic analyses and should consider the findings in generating each recommendation for which the panel decides to consider resource allocation issues.|
|6||Panels should apply clear and consistent criteria to the interpretation of economic analyses.|
|7||Panels considering resource allocation issues should specify the target audience explicitly.|
|8||Panels should explicitly address in the recommendation whether resource allocation issues differ substantially across the target audience and, if necessary, offer differing recommendations across segments of the target audience.|
|9||Panels should include one or more members with expertise in economic evaluation and should mandate that those members lead the group in consideration of resource allocation issues.|